GSM & Vine Parental Consent & Medical Release Form
Effective September 1, 2022 - August 31, 2023
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Student Name *
Student Date of Birth
Student Grade
Guardian Name
Street Address
City, State Zip
Phone # *
Email *
Name, Phone #, and Relationship to Student of Alternate Emergency Contact:
I hereby give permission for this student to participate in activities of Grace Church, Marshalltown, IA. This includes all sponsored activities on and off the Church property (inluding any and all activities involving travel and/or lodging) unless otherwise stated. I understand that reasonable precautions will be exercised by the adults chaperoning each event and that adults will adhere to the safety policies at all times. This permission shall remain in effect until August 31, 2023, unless terminated in writing. I hereby give permission for this student to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in church activities. I understand that drivers for all events must be over age 18 and approved by Grace Church Staff. In addition, I understand that my child may be photographed or recorded during the course of student ministry events and gatherings. By signing below I provide consent for their image to be used in either print, electronic, or video form for the promotional purposes of Grace Student Ministries. *
I understand I will be notified in the case of a medical emergency. However, in the event I cannot be reached, I authorize the approved Grace Church chaperone in charge to obtain any necessary medical attention in case of sickness or injury to my child. I understand the Grace Church adult chaperone will not be responsible for medical expenses incurred solely on the basis of this authorization. I hereby release and discharge Grace Church and all sponsors from any and all claims, demands, and actions or causes of action, past present, or future arising out of damage or injury while participating in church-sponsored student activities. I further agree to notify the student ministry pastor of any health changes that would restrict my student's participation in any normal student activities. I also understand that the student ministry leader and designated adult chaperone(s) reserve the right to restrict my student from any activity that they do not feel is within the physical capabilities of my student. *
Parent or Legal Guardian Signature (Electronic - Type Name) *
Date of Signature *
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